Many people at risk of type 2 diabetes do not know it, and a short questionnaire is often the first step toward testing. This form helps primary care practices, employer wellness programs, pharmacies, community health initiatives, and health coaches collect the risk factors a clinician needs to review before recommending next steps.
It starts with name, date of birth, and contact details, then gathers height, weight, and waist circumference so the reviewer can work out body mass index and central weight. Family history, gestational diabetes, and polycystic ovary syndrome come next, followed by physical activity, overall diet, fruit and vegetable intake, and smoking status. Questions about high blood pressure, high cholesterol, prediabetes, and heart disease complete the medical picture.
Respondents say when they last had a blood glucose or HbA1c test, and anyone who has had one is asked about the result. A symptom checklist covers signs such as increased thirst and blurred vision. The form finishes with medications, primary care physician, insurance status, and how the person would like to receive their results.
The form does not show a diagnosis or a score on screen. A provider reviews each submission and contacts the respondent, which keeps clinical judgment with the care team.
